Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003; 138(3): 161-7.
Tsilimingras D, Bates DW. Addressing postdischarge adverse events: a neglected area. Jt Comm J Qual Patient Saf. 2008; 34(2): 85-97.
Epstein K, Juarez E, Loya K, et al. Frequency of new or worsening symptoms in the posthospitalization period. J Hosp Med. 2007; 2(2): 58-68.
Coleman EA, Berenson RA. Lost in transition: challenges and opportunities for improving the quality of transitional care. Ann Intern Med. 2004; 141(7): 533-6.
Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006; 166(17): 1822-8.
Jack B, Bickmore T. The Re-Engineered Hospital Discharge Program to Decrease Rehospitalization. Care Management, 2011:p. 12-15.
Ggreenwald JL, Denham CR, Jack BW. The hospital discharge: a review of a high risk care transition with highlights of a reengineered discharge process. J Patient Saf. 2007; 3(2): 97-106.
Strunin L, Stone M, Jack B. Understanding rehospitalization risk: can hospital discharge be modified to reduce recurrent hospitalization? J Hosp Med. 2007; 2(5): 297-304.
Naylor MD. Nursing intervention research and quality of care: influencing the future of healthcare. Nurs Res. 2003; 52(6): 380-5.
Rau J, Medicare To Penalize 2,217 Hospitals For Excess Readmissions.
http://www.kaiserhealthnews.org/stories/2012/august/13/medicare-hospitals-readmissions-penalties.aspx, Accessed 2/10/2013.
Mollon B, Holbrook AM, Keshavjee K, et al. Automated telephone reminder messages can assist electronic diabetes care. J Telemed Telecare. 2008; 14(1): 32-6.
Chumbler NR, Mann WC, Wu S, et al. The association of home-telehealth use and care coordination with improvement of functional and cognitive functioning in frail elderly men. Telemed J e-Health. 2004; 10(2): 129-37.
Cassimatis M, Kavanagh DJ. Effects of type 2 diabetes behavioural telehealth interventions on glycaemic control and adherence: a systematic review. J Telemed Telecare. 2012; 18(8): 447-50.
Corkrey R, Parkinson L. Interactive voice response: review of studies 1989–2000. Behav Res Methods Instrum Comput. 2002; 34(3): 342-353.
Crawford AG, Sikirica V, Goldfarb N, et al. Interactive voice response reminder effects on preventive service utilization. Am J Med Qual. 2005; 20(6): 329-36.
Bender BG, Apter A, Bogen DK, et al. Test of an interactive voice response intervention to improve adherence to controller medications in adults with asthma. J Am Board Fam Med. 2010; 23(2): 159-65.
Magid DJ, Ho PM, Olson KL, et al. A multimodal blood pressure control intervention in 3 healthcare systems. Am J Manag Care. 2011; 17(4): e96-103.
Xu C, Jackson M, Scuffham PA, et al. A randomized controlled trial of an interactive voice response telephone system and specialist nurse support for childhood asthma management. J Asthma. 2010; 47(7): 768-73.
Graham J, Tomcavage J, Salek D, et al. Postdischarge monitoring using interactive voice response system reduces 30-day readmission rates in a case-managed Medicare population. Med Care. 2012; 50(1): 50-7.
Academic E.D.S.R.C. The impact of screening, brief intervention and referral for treatment in emergency department patients’ alcohol use: a 3-, 6- and 12-month follow-up. Alcohol Alcohol. 2010; 45(6): 514-9.
Chaudhry SI, Mattera JA, Curtis JP, et al. Telemonitoring in patients with heart failure. N Engl J Med. 2010; 363(24): 2301-9.
Ritchie C, Richman J, Sobko H, et al. The E-coach transition support computer telephony implementation study: protocol of a randomized trial. Contemp Clin Trials. 2012; 33(6): 1172-9.
Sullivan MD, Levy WC, Russo JE, et al. Summary health status measures in advanced heart failure: relationship to clinical variables and outcome. J Card Fail. 2007; 13(7): 560-568.
Thorpe KE, Zwarenstein M, Oxman AD, et al. A pragmatic-explanatory continuum indicator summary (PRECIS): a tool to help trial designers. CMAJ. 2009; 180(10): E47-57.
Katzman R, Brown T, Fuld P, et al. Validation of a short Orientation-Memory-Concentration Test of cognitive impairment. Am J Psychiatry. 1983; 140(6): 734-9.
Linden A, Butterworth SW, Prochaska JO. Motivational interviewing-based health coaching as a chronic care intervention. J Eval Clin Pract. 2010; 16(1): 166-74.
Coleman EA, Mahoney E, Parry C. Assessing the quality of preparation for posthospital care from the patient’s perspective: the care transitions measure. Med Care. 2005; 43(3): 246-55.
Coleman EA, Smith JD, Frank JC, et al. Preparing patients and caregivers to participate in care delivered across settings: the Care Transitions Intervention. J Am Geriatr Soc. 2004; 52(11): 1817-25.
Wallace LS, Rogers ES, Roskos SE, et al. Brief report: screening items to identify patients with limited health literacy skills. J Gen Intern Med. 2006; 21(8): 874-7.
Salvi F, Miller MD, Grilli A, et al. A manual of guidelines to score the modified cumulative illness rating scale and its validation in acute hospitalized elderly patients. J Am Geriatr Soc. 2008; 56(10): 1926-31.
Takahashi PY, Pecina JL, Upatising B, et al. A randomized controlled trial of telemonitoring in older adults with multiple health issues to prevent hospitalizations and emergency department visits. Arch Intern Med. 2012; 172(10): 773-9.
Vinson JM, Rich MW, Sperry JC, et al. Early readmission of elderly patients with congestive heart failure. J Am Geriatr Soc. 1990; 38(12): 1290-5.
Harrison MB, Browne GB, Roberts J, et al. Quality of life of individuals with heart failure: a randomized trial of the effectiveness of two models of hospital-to-home transition. Med Care. 2002; 40(4): 271-82.
Pinnock H, Hanley J, McCloughan L, et al. Effectiveness of telemonitoring integrated into existing clinical services on hospital admission for exacerbation of chronic obstructive pulmonary disease: researcher blind, multicentre, randomised controlled trial. BMJ. 2013; 347: f6070.
Flodgren G, Rachas A, Farmer AJ, et al. Interactive telemedicine: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2015; 9, CD002098.
Piette JD, Striplin D, Marinec N, et al. A Mobile Health Intervention Supporting Heart Failure Patients and Their Informal Caregivers: A Randomized Comparative Effectiveness Trial. J Med Internet Res. 2015; 17(6), e142.
Sherrard H, Duchesne L, Wells G, et al. Using interactive voice response to improve disease management and compliance with acute coronary syndrome best practice guidelines: A randomized controlled trial. Can J Cardiovasc Nurs. 2015; 25:(1).
Thomson M, Volk M, Kim HM, Piette JD. An Automated Telephone Monitoring System to Identify Patients with Cirrhosis at Risk of Re-hospitalization. Dig Dis Sci. 2015; 60(12): 3563-9.
Foust JB, Naylor MD, Boling PA, Cappuzzo KA. Opportunities for improving post-hospital home medication management among older adults. Home Health Care Serv Q. 2005; 24(1-2): 101-22.
Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003; 18(8): 646-51.
Willig JH, Krawitz M, Panjamapirom A, et al. Closing the Feedback Loop: An Interactive Voice Response System to Provide Follow-up and Feedback in Primary Care Settings. J Med Syst. 2013; 37(2): 9905.
Haas JS, Iyer A, Orav EJ, et al. Participation in an ambulatory e-pharmacovigilance system. Pharmacoepidemiol Drug Saf. 2010; 19(9): 961-9.